Hospital design features that optimise pandemic response

The COVID-19 pandemic has changed forever how we plan, respond to, and deliver health care. The lived experience of hospital infrastructure design to support a pandemic is currently not well described in the literature. Much of what is known covers generic elements of hospital design and/or assumptions about in-built disaster design features. The Central Adelaide Local Health Network became a key stakeholder in South Australia's response when the Royal Adelaide Hospital (RAH) became the designated receiving hospital for the state. Preparation for a pandemic commenced back in 2007 when a new build for the RAH was announced. Several disaster response infrastructure design features were incorporated into the RAH design specifications to provide a resilient facility that could respond to any type of disaster event while continuing to provide core clinical services. Key pandemic design elements included patient room design, pandemic air handling capability, and a 7-step scalability function. We describe these key elements based on real-time experience along with the key lessons learnt as the pandemic response evolved with the aim of guiding future hospital building design to not only support the more frequent time-limited disasters but, more specifically, a pandemic response. The RAH capitalised on its key design features to support its pandemic response and contributed to the overall success of South Australia's pandemic response.

Principles of capacity management, applied in the mental health context

Objective The aim of the paper was to describe a suite of capacity management principles that have been applied in the mental health setting that resulted in a significant reduction in time spent in two emergency departments (ED) and improved throughput. Methods The project consisted of a multifocal change approach over three phases that included: (1) the implementation of a suite of fundamental capacity management activities led by the service and clinical director; (2) a targeted Winter Demand Plan supported by McKinsey and Co.; and (3) a sustainability of change phase. Descriptive statistics was used to analyse the performance data that was collected through-out the project. Results This capacity management project has resulted in sustained patient flow improvement. There was a reduction in the average length of stay (LOS) in the ED for consumers with mental health presentations to the ED. At the commencement of the project, in July 2014, the average LOS was 20.5h compared with 8.5h in December 2015 post the sustainability phase. In July 2014, the percentage of consumers staying longer than 24h was 26% (n=112); in November and December 2015, this had reduced to 6% and 7 5% respectively (less than one consumer per day). Conclusion Improving patient flow is multifactorial. Increased attendances in public EDs by people with mental health problems and the lengthening boarding in the ED affect the overall ED throughput. Key strategies to improve mental health consumer flow need to focus on engagement, leadership, embedding fundamentals, managing and target setting. What is known about the topic? Improving patient flow in the acute sector is an emerging topic in the health literature in response to increasing pressures of access block in EDs. What does this paper add? This paper describes the application of a suite of patient flow improvement principles that were applied in the mental health setting that significantly reduced the waiting time for consumers in two EDs. What are the implications for practitioners? No single improvement will reduce access block in the ED for mental health consumers. Reductions in waiting times require a concerted, multifocal approach across all components of the acute mental health journey.

Developing an evaluation framework for clinical redesign programs: lessons learnt

Purpose The purpose of this paper is to present lessons learnt through the development of an evaluation framework for a clinical redesign programme - the aim of which was to improve the patient journey through improved discharge practices within an Australian public hospital. Design/methodology/approach The development of the evaluation framework involved three stages - namely, the analysis of secondary data relating to the discharge planning pathway; the analysis of primary data including field-notes and interview transcripts on hospital processes; and the triangulation of these data sets to devise the framework. The evaluation framework ensured that resource use, process management, patient satisfaction, and staff well-being and productivity were each connected with measures, targets, and the aim of clinical redesign programme. Findings The application of business process management and a balanced scorecard enabled a different way of framing the evaluation, ensuring measurable outcomes were connected to inputs and outputs. Lessons learnt include: first, the importance of mixed-methods research to devise the framework and evaluate the redesigned processes; second, the need for appropriate tools and resources to adequately capture change across the different domains of the redesign programme; and third, the value of developing and applying an evaluative framework progressively. Research limitations/implications The evaluation framework is limited by its retrospective application to a clinical process redesign programme. Originality/value This research supports benchmarking with national and international practices in relation to best practice healthcare redesign processes. Additionally, it provides a theoretical contribution on evaluating health services improvement and redesign initiatives.

Seeking an Explanation for the Poor Uptake of In-Hospital AED Programs

The automated external defibrillator (AED) has been adopted by emergency service personnel as a first-line intervention in the management of out-of-hospital cardiac arrest (OHCA). AED leads to more successful Advanced Cardiac Life Support; consequently, national resuscitation organisations worldwide have recommended that nurses and doctors also integrate AEDs as a component of their basic life-support response to cardiac arrest. Despite these recommendations, the implementation of AED programs within hospitals has been generally sporadic and isolated. A continuation of this situation will most likely disturb and perplex nurses and patients, as they are key stakeholders with respect to upholding recommended BLS practices. In the absence of any explanation from change agents within hospitals, this paper seeks, by way of a pilot study and a review of the literature, to identify the extent of the problem and identify factors contributing to the relatively slow uptake of this device. We argue that nurses and other first responders to in-hospital cardiac arrest (CA) have much to gain, in the context of Occupational Health Safety and Welfare (OHS and W), from ready access to AEDs. Cost factors are also considered, with initial cost of AED purchase likely to be a major concern for managers of hospital budgets. The issues we discuss in this paper clearly support the need for further research to (a) explain the nature of public hospital resistance to AEDs and (b) to consider whether AEDs will provide practical advantages to public hospitals from an occupational, social and economic perspective.

Discharge timeliness and its impact on hospital crowding and emergency department flow performance

OBJECTIVE

The objective of this research is to identify optimal inpatient discharge time targets to help hospitals reduce crowding, improve patient flow through the ED and balance staff workload.

METHODS

Fifteen months of emergency and inpatient records from a large quaternary teaching hospital were used to reconstruct patient pathways from hospital presentation to discharge. Discrete event simulation was used to assess operationally realistic discharge scenarios on flow performance. Main output measures included National Emergency Access Target (NEAT) performance (an ED performance metric), time spent waiting for a bed, hospital length of stay (LOS) and occupancy.

RESULTS

Similar levels of improvement in NEAT performance (16%), and reductions in average bed occupancy (1.5%) and inpatient bed wait time (25%) were observed across the simulation that discharged 80% patients before 11 a.m. and one that spread the target between 10 a.m. and 2 p.m. Individual inpatient wards returned potential improvements in NEAT performance (median 10%, interquartile range (IQR) 7%), and reductions in hospital LOS (median 1%, IQR 1%) and average occupancy (median 1%, IQR 2%) across the discharge scenarios.

CONCLUSIONS

Conventional discharge targets like '80% by 11 a.m.' and others that spread targets across the day to balance staff workload freed up the equivalent of nine available beds for incoming patient flow, significantly reducing time spent waiting for an inpatient bed, hospital LOS and occupancy, and delivering much needed improvements in NEAT performance. While different strategies and workload distributions may suit individual hospital services, the study makes a strong case for improving 'early in the day' discharge timeliness to deliver better ED flow.

Use of a capacity audit tool in a mental health setting

OBJECTIVE

This paper reports on a pilot applying the capacity audit tool (CAT) in a mental health environment and what the tool reveals regarding mental health in-patient capacity issues.

METHODS

The CAT was modified to create an electronic mental health-relevant tool to audit acute in-patient capacity. This tool was then piloted across nine bedded units, within a single Local Health Network, covering a total of 153 mental health beds.

RESULTS

The application of the mental health CAT resulted in 100% compliance in completion. The findings revealed that 16% (25 beds) of the 153 beds surveyed were occupied by patients who did not need to occupy the bed or the bed was vacant. Of these 25 beds, 10 had patients awaiting transfer to another facility or service, nine were empty and six were occupied by patients ready for discharge but for whom there were delays.

CONCLUSION

The CAT was successfully applied to the mental health setting and identified a set of opportunities to improve processes and practices to reduce the identified delays or barriers in order to improve patient flow.

Injury occurrences at a Mass Gathering Event

Introduction This study identifies injuries that arise at a public event in an environment where multiple industries, service providers and patrons are present simultaneously. Methods A prospective survey method was used to collect data relating to injuries occurring at the event. The event was the Royal Adelaide Show, a 9-day agricultural and horticultural show hosted in a capital city in Australia during 2002. All patients who presented to St John Volunteers for treatment were the population for this study with the sample population being people who sustained an injury at the event. Results Crowd attendance over the nine days was 622,234. A total of 1028 patients presented for treatment with 265 (26%) being the result of injury. It was observed that minor wounds were the most common injury treated (18%), followed closely by lacerations (17%). The majority of injuries occurring at the event were minor in nature. There were 42 persons injured while working at the event. Of these, 9 (21%) required transfer to hospital by ambulance. Conclusion At the event studied, there were a number of injuries occurring that required treatment/management. On average, there was one worker transported to hospital by ambulance each day of the event. There may be a role for more formalised injury surveillance at mass gathering events to assess and monitor injury trends to both patrons and workers in this dynamic setting.

Tradition, rituals and standards, in a realm of evidenced based nursing care

Evidenced-based nursing is seen as the future of nursing but the real world in which practice occurs is limiting the possibilities for change. The practice of post-operative (PO) vital sign collection in the general ward setting is described as an example of the complexities that surround practice. Despite the ongoing work around evidenced-based practice, elements of nursing practice remain based on tradition. Routines and rituals are driving care rather than clinical judgement. The complexities of practice limit the possibilities for change. These complexities include the systems in which nurses' practice, the fear of medico-legal repercussions, and the sense of security that rituals provide. This paper discusses these themes including the barriers to change and the implications for practice. The development of evidenced-based practice is only one component of the solution to the provision of best practice. Care is required to ensure that the evidenced-based movement does not lead to recipe book care rather than patient centred practice.

Using capacity alert calls to reduce overcrowding in a major public hospital

OBJECTIVE

To investigate the efficacy of capacity alert calls in reducing acute hospital overcrowding through addressing rising occupancy, high patient throughput and increased access block.

METHODS

Retrospective analysis of 24 months of in-patient, emergency department, and capacity alert call log data from a large metropolitan public hospital in Australia. The analysis explored statistical differences in patient flow parameters between capacity alert call days and other days including a control case set of days with statistically similar levels of occupancy.

RESULTS

The study identified a significant (P<0.05) reduction in occupancy, patient throughput and access block on capacity alert call days. Capacity alert call days reversed rising occupancy trends, with 6 out of 7 flow parameters reporting significant improvement (P<0.05) over the 48 h following the call. Only 3 of these 7 flow parameters were significantly improved 48 h after control case days, confirming value in the alert mechanism and that the results are not a regression toward the mean phenomenon. CONCLUSIONS Escalation processes that alert and engage the whole hospital in tackling overcrowding can successfully deliver sustained improvements in occupancy, patient throughput and access block. The findings support and validate the use of capacity alert escalation calls to manage overcrowding, but suggest the need to improve the consistency of trigger mechanisms and the efficiency of the processes initiated by the capacity alert call.

Probability of severe adverse events as a function of hospital occupancy

A unique application of regression modeling is described to compare hospital bed occupancy with reported severe adverse events amongst inpatients. The probabilities of the occurrence of adverse events as a function of hospital occupancy are calculated using logistic and multinomial regression models. All models indicate that higher occupancy rates lead to an increase in adverse events. The analysis identified that at an occupancy level of 100%, there is a 22% chance of one severe event occurring and a 28% chance of at least one severe event occurring. This modeling contributes evidence toward the management of hospital occupancy to benefit patient outcomes.

Elektronenbeugungsbestimmung der Molekülstruktur von 4-Fluor-2′,4′,6′ -trimethylbiphenyl / Molecular Structure of 4-Fluoro-2′,4′,6′-trimethylbiphenyl Determined by Electron Diffraction

The molecular structure of gaseous 4-fluoro-2′,4′,6′-trimethylbiphenyl was determined by electron diffraction. The average of two independend determinations leads to the following parameters for the structure:

CC(ring) = 1.398(1),CC(methyl) = 1.522(5), CH(ring) = 1.082(6), CH(methyl) = CH(ring) + 0.015 = 1.097(6), CF = 1.324(7), Cl-Cl′ = 1.488(9) (inter ring bond), ∢(C,C,H) = 109.9(1.8)° (angle of methylgroup tetrahedra), α = 124.9(0.6)° (angle of ortho-methyl-groups towards the inter ring bond), φ = 77.5(2.1)° (angle of torsion between the planes of the two phenyl rings) which are in good agreement with respect to known structural data on biphenylderivatives. A very interesting result is the angle of torsion with 77.5° which is by 6.5° smaller than the value of 84(1)° determined by X-ray crystallography for the corresponding 4-iodo-compound in the crystalline state1. In all determinations known to us til now for comparable derivatives of biphenyl the angle of torsion was found larger in the gaseous state than in the crystalline state.

Flexing bed stock: a hospital capacity management case study

As hospitals struggle to meet rising demand for their services, efficient capacity management is critical to the success of their efforts. A popular strategy employed by hospitals to meet the variability in demand for their services is to 'flex' their capacity, i.e. to vary the number of available staffed beds to suit demand on a regular basis. This study uses data from a large tertiary hospital in South Australia to analyze the efficacy of their flexing protocols and the impact of flexing capacity on overcrowding. We also analyze the impact of variation in occupancy on patient flow parameters and compare this to previous studies conducted on similar sized Australian hospitals that do not flex capacity. Our findings reveal that flexing capacity helps the hospital spend less time over critical occupancy levels, and that the hospital does not show the signs of performance decline exhibited by hospitals that do not flex capacity. Areas for improvements in the flexing protocol and possible strategies are also identified. The findings support the use of flexing capacity as an efficient protocol and will serve as a useful guide for services seeking to improve existing capacity management protocols.

Time based clustering for analyzing acute hospital patient flow

This paper describes a novel approach employing time based clustering of health data for visualization and analysis of patient flow. Clustering inpatient and emergency department patient episodes into hourly slots based on recorded timestamps, and then grouping them on required parameters, the technique provides a powerful tool for visualizing and analyzing interactions and interdependencies between hospital patient flow parameters. To demonstrate the efficacy of the approach, we employ time based clustering to address some typical patient flow related queries and discuss the findings.

Understanding the drivers on medical workloads: an analysis of spectators at the Australian Football League

Objective. The present study was designed to further understand the psychosocial drivers of crowds impacting on the demand for healthcare. This involved analysing different spectator crowds for medical usage at mass gatherings; more specifically, did different football team spectators (of the Australian Football League) generate different medical usage rates. Methods. In total, 317 games were analysed from 10 venues over 2 years. Data were analysed by the ANOVA and Pearson correlation tests. Results. Spectators who supported different football teams generated statistically significant differences in patient presentation rates (PPR) (F15, 618 = 1.998, P = 0.014). The present study confirmed previous findings that there is a positive correlation between the crowd size and PPR at mass gatherings but found a negative correlation between density and PPR (r = –0.206, n = 317, P < 0.0005). Conclusions. The present study has attempted to scientifically explore psychosocial elements of crowd behaviour as a driver of demand for emergency medical care. In measuring demand for emergency medical services there is a need to develop a more sophisticated understanding of a variety of drivers in addition to traditional metrics such as temperature, crowd size and other physical elements. In this study we saw that spectators who supported different football teams generated statistically significant differences in PPR. What is known about this topic? Understanding the drivers of emergency medical care is most important in the mass gathering setting. There has been minimal analysis of psychological ‘crowd’ variables. What does this paper add? This study explores the psychosocial impact of supporting a different team on the PPR of spectators at Australian Football League matches. The value of collecting and analysing these types of data sets is to support more balanced planning, better decision support and knowledge management, and more effective emergency medical demand management. What are the implications for practitioners? This information further expands the body of evidence being created to understand the drivers of emergency medical demand and usage. In addition, it supports the planning and management of emergency medical and health-related requirements by increasing our understanding of the effect of elements of ‘crowd’ that impact on medical usage and emergency healthcare.

Does hospital occupancy impact discharge rates?

Objective. To understand what impact hospital inpatient occupancy levels have on patient throughput by analysing one hospital’s occupancy levels and the rate of patient discharge. Methods. A four-stage model was fit to hospital admission and separation data and used to analyse the per-capita separation rate according to the patient load and the impact of hospital over-census actions. Results. Per-capita separation rates are significantly higher on days when the hospital declares an over-census due to emergency department crowding. Per-capita separation rates are also higher or lower on days with 8−10% higher or lower patient loads, respectively, but the response is not nearly as strong as the response to an over-census declaration, and is limited to patients with an elapsed stay of 10 days or more. Within the medical division there is an increase in per-capita separation rates on over-census days, but no significant difference in per-capita release rates for different patient loads. Within the surgical division there is no significant difference in per-capita separation rates on over-census days compared with other days, but the patient load does make a significant difference. Conclusion. Staff do discharge a greater proportion of long-stay patients when the hospital is experiencing high demand and a lower proportion when occupancy is low, but the reasons driving those changes remains unclear. What is known about the topic? The evidence regarding safe and efficient levels of hospital occupancy is limited. There is minimal empirical evidence that confirms the relationship between occupancy and discharge rates. What does the paper add? Per-capita separation rates increase strongly on over-census days. The hospital increases per-capita separation rates on days of high occupancy and reduces it on days of low occupancy, mostly for long-stay patients with over 10 days of elapsed stay. The response to high occupancy is not as strong as the response to over-census. The medical division responds strongly to the over-census and the surgical division does not. The surgical division responds more to occupancy levels within its own division than does the medical division. What are the implications for practitioners? The implementation of over-census-type responses to periods of high occupancy may result in increased per-capita separation rate. Using mathematical analysis to understand patient load on per capita separation is important to create a better understanding of health service delivery, thereby aiding hospital managers, and has the potential to guide system improvement. The clinical drivers for these changes and the service design implications require further investigation.

Improving the fundamentals of care for older people in the acute hospital setting: facilitating practice improvement using a Knowledge Translation Toolkit

This paper reports on a structured facilitation program where seven interdisciplinary teams conducted projects aimed at improving the care of the older person in the acute sector. Aims  To develop and implement a structured intervention known as the Knowledge Translation (KT) Toolkit to improve the fundamentals of care for the older person in the acute care sector. Three hypotheses were tested: (i) frontline staff can be facilitated to use existing quality improvement tools and techniques and other resources (the KT Toolkit) in order to improve care of older people in the acute hospital setting; (ii) fundamental aspects of care for older people in the acute hospital setting can be improved through the introduction and use of specific evidence-based guidelines by frontline staff; and (iii) innovations can be introduced and improvements made to care within a 12-month cycle/timeframe with appropriate facilitation. Methods  Using realistic evaluation methodology the impact of a structured facilitation program (the KT Toolkit) was assessed with the aim of providing a deeper understanding of how a range of tools, techniques and strategies may be used by clinicians to improve care. The intervention comprised three elements: the facilitation team recruited for specific knowledge, skills and expertise in KT, evidence-based practice and quality and safety; the facilitation, including a structured program of education, ongoing support and communication; and finally the components of the toolkit including elements already used within the study organisation. Results  Small improvements in care were shown. The results for the individual projects varied from clarifying issues of concern and planning ongoing activities, to changing existing practices, to improving actual patient outcomes such as reducing functional decline. More importantly the study described how teams of clinicians can be facilitated using a structured program to conduct practice improvement activities with sufficient flexibility to meet the individual needs of the teams. Conclusions  The range of tools in the KT Toolkit were found to be helpful, but not all tools needed to be used to achieve successful results. Facilitation of the teams was a central feature of the KT Toolkit and allowed clinicians to retain control of their projects; however, finding the balance between structuring the process and enabling teams to maintain ownership and control was an ongoing challenge. Clinicians may not have the requisite skills and experience in basic standard setting, audit and evaluation and it was therefore important to address this throughout the project. In time this builds capacity throughout the organisation. Identifying evidence to support practice is a challenge to clinicians. Evidence-based guidelines often lack specificity and were found to be difficult to assimilate easily into everyday practice. Evidence to inform practice needs to be provided in a variety of forms and formats that allow clinicians to easily identify the source of the evidence and then develop local standards specific to their needs. The work that began with this project will continue - all teams felt that the work was only starting rather than concluding. This created momentum, motivation and greater ownership of improvements at local level.

What are the core elements of patient-centred care? A narrative review and synthesis of the literature from health policy, medicine and nursing

AIM

To identify the common, core elements of patient-centred care in the health policy, medical and nursing literature.

BACKGROUND

Healthcare reform is being driven by the rhetoric around patient-centred care yet no common definition exists and few integrated reviews undertaken.

DESIGN

Narrative review and synthesis.

DATA SOURCES

Key seminal texts and papers from patient organizations, policy documents, and medical and nursing studies which looked at patient-centred care in the acute care setting. Search sources included Medline, CINHAL, SCOPUS, and primary policy documents and texts covering the period from 1990-March 2010.

REVIEW METHODS

A narrative review and synthesis was undertaken including empirical, descriptive, and discursive papers. Initially, generic search terms were used to capture relevant literature; the selection process was narrowed to seminal texts (Stage 1 of the review) and papers from three key areas (in Stage 2).

RESULTS

In total, 60 papers were included in the review and synthesis. Seven were from health policy, 22 from medicine, and 31 from nursing literature. Few common definitions were found across the literature. Three core themes, however, were identified: patient participation and involvement, the relationship between the patient and the healthcare professional, and the context where care is delivered.

CONCLUSION

Three core themes describing patient-centred care have emerged from the health policy, medical, and nursing literature. This may indicate a common conceptual source. Different professional groups tend to focus on or emphasize different elements within the themes. This may affect the success of implementing patient-centred care in practice.

The reality of multiple casualty triage: putting triage theory into practice at the scene of multiple casualty vehicular accidents

OBJECTIVES

The project investigated the experiences of ambulance paramedics in applying the principles and protocols of prehospital multiple casualty triage at the scene of motor vehicle accidents. Key objectives included investigation of the situational cues and other contextual factors influencing triage practice and the development of recommendations for the future education of ambulance paramedics.

METHODS

A triangulated approach was used incorporating demographic data, the use of focus groups and in-depth interviews. A thematic analysis was undertaken following the well established practices of human science research.

RESULTS AND CONCLUSIONS

The research describes an extended and broadened triage process returning to a more authentic definition of triage as the practice of sorting of casualties to determine priority. The findings highlight the need to consider triage as an extended and complex process that incorporates evidence based physiological cues to assist decision making and the management of the process of triage from call out to conclusion including assessment of contextual and situational variables.

Latex allergy in the prehospital setting

INTRODUCTION

Latex allergy first was recognized early in the 20th Century, but was not a matter of concern until the last decade of that Century. The reported incidence of latex allergy in different occupations varies considerably. It has been documented in dental workers, operating theater staff, anesthetists, and laboratory technicians. However, little data specifically related to those involved in patient care in the emergency prehospital setting are available.

METHODS

A questionnaire was distributed to a sample of both volunteer and salaried first responders from St. John Ambulance Australia in South Australia and Western Australia, and the South Australian Ambulance Service. The first responders were surveyed to: (1) determine the incidence of latex allergy; (2) consider possible factors associated with its development; (3) compare characteristics of the surveyed groups; and (4) reinforce the development of an educational program. The study tool had predetermined statistical qualities. Data were collated and processed using standard statistical procedures. Surveys were collected anonymously.

RESULTS

Of the 2,716 forms distributed, 1,099 were returned, resulting in an overall response rate of 40.5%. Atopy was identified in 14.9% of participants, hand dermatitis in 9.4%, and latex allergy in 6.4%. In the group of full-time ambulance officers, there was a significantly higher incidence of hand dermatitis and latex allergy. There also was a significant relationship between latex allergies and both dermatitis and glove usage (as measured by frequency and duration).

CONCLUSION

In a group of first responders assessed by an anonymous, voluntary questionnaire, the subset of full-time, salaried ambulance officers was identified as having a higher incidence of hand dermatitis and latex allergy than their volunteer co-workers. These results require further assessment to substantiate the frequency of latex allergy and determine the predisposing factors. All personnel must learn about hand care. Non-powdered, natural rubber latex gloves should be supported for general use in this setting.

Observations and vital signs: ritual or vital for the monitoring of postoperative patients?

Patient surveillance during the postoperative period has traditionally consisted of the collection of routine and regulated vital signs, supported by observations of other aspects of a patient's recovery. The purpose of this research was to determine if the frequent collection of postoperative vital signs assisted in detecting postoperative complications in the first 24 hours after a patient has returned to the ward setting. The study involved: (1) a survey of policy documents; (2) observations of postoperative nursing care; and (3) an audit of medical records. Major findings revealed that vital signs are collected based on tradition and are collected routinely, and there may not be a relationship between vital-signs collection and the occurrence or detection of complications.

Australian issues in the provision of after-hours primary medical care services in rural communities

OBJECTIVE

In 2003 the Rural Doctors Workforce Agency in South Australia (SA) facilitated the 'SA Rural Hospital After Hours Triage Education and Training Program'. It was designed to improve communication between rural general practitioners (GPs) and nurses undertaking after-hours triage, provide training in triage for rural nurses and develop local collaborative after-hours primary medical care models that can be applied in other settings.

DESIGN

The program consisted of a series of three workshops. The first workshop provided an opportunity for GPs and nurses to discuss local issues relating to after-hours primary medical care service delivery. This was followed by a one-day workshop on triage for nurses. A follow-up refresher workshop was conducted approximately six months later.

SETTING

Twenty-three rural communities in SA.

PARTICIPANTS

Rural GPs and nurses working in rural communities.

RESULTS

This paper reports on the issues highlighted by clinicians in providing after-hours primary medical care in rural and remote communities. These included community expectations, systems of care, scope of practice, private practice/public hospital interface, and medico legal issues.

CONCLUSION

The issues facing after-hours health services in rural communities are not new. There are many opportunities for improvement of systems. A formal program including workshops and training has provided a useful forum to commence service improvements.

Nursing observations during the first 24 hours after a surgical procedure: what do we do?

AIMS AND OBJECTIVES

The purpose of the study was to describe what constitutes postoperative nursing monitoring during the initial 24 hours on the ward including the components of observation, frequency and time spent with patients.

BACKGROUND

The literature provides little guidance as to the best practice of postoperative surveillance. To understand the practice of monitoring patients after returning to the ward from a surgical procedure it is important to describe the current practice.

DESIGN

The study involved a non-participant observation of nursing practice.

METHOD

Data were generated via observation of postoperative patients in the first 24 hours after returning to the ward. This occurred in the general surgical units of two different South Australian hospitals over an 8-week period.

RESULTS

A total of 81 patients were observed for 282 patient hours. Vital sign collection generally reflected a traditional pattern of hourly for the first four hours, reducing to four hourly across the 12- to 24-hour period. The frequency and duration of patient-nurse interactions, observations recorded and the collection of other clinical data such as pain, oxygen saturations and nausea are also discussed.

RELEVANCE TO CLINICAL PRACTICE

The findings presented here depict the current nursing practice of postoperative monitoring in two different settings, providing insight into what constitutes contemporary postoperative surveillance.

CONCLUSION

Before inroads can be made to identify the best practice of postoperative patient surveillance a clear cognisance of practice needs to be identified.

Postoperative complications in the first 24 hours: a general surgery audit

BACKGROUND

Traditionally, the purpose of routine postoperative surveillance has been to detect postoperative complications. The literature reports well-documented, procedure-specific postoperative complication rates. However, there are no reports detailing the prevalence of postoperative complications in general surgical ward settings, where nurses care for patients following a variety of surgical procedures.

AIMS

This paper reports an audit of the frequency and type of postoperative complications in a general surgical population occurring in the first 24 hours postoperatively.

METHOD

A patient record audit was undertaken for all postoperative patients who returned to two general surgical wards. This was conducted sequentially, involving a 4 week data collection phase in each participating ward during 2001.

RESULTS

The audit sample comprised 144 patient records with an average patient age of 54 years. Statistically significant results included the rate of postoperative nausea and vomiting of 37.5% (n = 54), and 17% (n = 25) of patients experiencing another 'clinical event'.

LIMITATIONS

The findings reflect only those complications recorded/documented in postoperative patients' records, and cannot be generalized beyond the sample and setting.

CONCLUSIONS

Postoperative patients cared for on general surgical wards experienced a high level of nausea and vomiting, while the occurrence of life-threatening complications was small.

Evidence-based practice: To be or not to be, this is the question!

Evidence-based nursing is the current fashion. It is being touted as the mechanism to achieve best practice in the clinical setting. But while evidence-based practice (EBP) is being presented in the literature, discussed at nursing practice forums, and evidence-based centres of excellence have developed, there seems to be very little impact in the practice that nurses deliver on a daily basis. The case in point is the collection of vital signs. While not historically a nursing skill, over the last 60 years it has become an integral component of practice in the postoperative general surgical setting. The evidence to support these practices is scant. Policies and text purport traditional routine-regulated practice without substantive evidence to support their claims. These policies are being used to control rather than support EBP. In conjunction with the traditional practice of vital sign collection and the culture of the clinical settings, the policies are limiting opportunities for clinicians to make individual decisions about care delivery based on the unique needs of each patient. Rather than focusing on EBP as the solution to the development of best practice, is it not time to change the focus to real strategies that will assist in achieving best practice? These include the creation of rigorous relevant evidence, the valuing of clinical expertise and the changing of the cultures in which nurses develop and practice.

Policies that drive the nursing practice of postoperative observations

Postoperative nursing care traditionally has involved the utilisation of regulated, routine patient observation to monitor patient progress. This study was designed to review the policy/procedure documentation that drives this practice and to determine who contributes to policy development. In all, 75 surgical hospitals were surveyed, producing 47 procedures for content analysis. Findings suggest that there is a great diversity in procedures between organisations. The most common pattern of postoperative vital sign collection is hourly for 4 h and then 4 hourly in 27% of the regimes. On average a patient receives 10 sets of observation in the first 24 h, with neurovascular, wound and drain checks the most frequent observations collected in addition to vital signs.

Nurses as patients: the voyage of discovery

To facilitate an enhanced understanding of the experience of being a patient, an inquiry was undertaken into the experience of nurses receiving nursing care when hospitalized. Using a hermeneutic-phenomenological approach, an exploration was undertaken of registered nurses' interpretations of their experiences of receiving nursing care, as described in their individual stories. By interpreting the text generated by the inquiry, it was possible to explore the uniqueness and commonalities of these experiences. This resulted in 10 themes that exemplified the nurses' experiences. The interpretation uncovered the voice of the nurse in the experience of being a patient, insight into how patients perceive being a patient and reflections by the nurse patients on quality nursing care. This research has provided insight into the value of the relationship between the nurse and the patient and insight into the significance of the nature of care delivery.